Employment Application

Employment Application

Employment Application

(You may request assistance in completing this application)

Our Mission

Rooted in the legacy of the Dominican Sisters of Peace, Sansbury Care Center’s Mission is to provide high quality, personalized, compassionate care services to the Sisters and lay women residents who reside at the facility. We hold five values central to this Mission:

P Person-centered high quality care
E Empowered employees through training and education
A Attitude and behaviors aligned with our legacy
C Compassionate environment responding to the needs of all
E Excellence in nurturing the whole person

Conditions of Employment

Before completing and submitting the below Employment Application form, it is important that you read and understand the following “Conditions of Employment.” By completing and submitting the form, you are stating that you have read, understand and agree to the Conditions of Employment as noted below.

Conditions of Employment

The facts as stated on this Application are true and correct. I understand that, if employed, false statements on this Application may cause my immediate dismissal.

I authorize whatever background and personal reports needed to verify the information I have supplied is true and accurate, and to determine my fitness for this job and hold harmless those who have the responsibility to develop such reports. A copy of this authorization is as valid as the original. I understand that the results of a criminal record check may result in the withdrawal of a job offer.

I accept that I may be required to work overtime as a condition of being employed.

In consideration of my employment, I agree to conform to the rules and regulations for employees. I understand I am an employee at-will, and that this application may never be considered to be a contract of employment with the Sansbury Care Center, Inc. or me. I understand that no representative of Sansbury Care Center, Inc. has any authority to enter into a verbal agreement for employment for any specified period of time or to make any agreement contrary to the foregoing and that no document, policy or practice of Sansbury Care Center, Inc. may change the foregoing unless it is expressly titled “Employment Agreement” and signed by both myself and the Chief Executive Officer of Sansbury Care Center, Inc.

I understand that I may be required to submit to pre-employment and/or post-employment tests for fitness and/or substance abuse, if not prohibited by law.

Upon separation of employment, I authorize Sansbury Care Center, Inc. to withhold from my final paycheck and monies owed to them by me (if not prohibited) for equipment, loans, keys, name badge, products, services, materials or other assets in my possession not promptly returned.

For this type of employment, state law requires criminal records checks as a condition of employment and may prohibit an applicant’s employment here at Sansbury Care Center, Inc. including the withdrawal of the job offer.

SPECIAL NOTE: You are not required to supply any information that is prohibited by Federal, State or Local law. We are an Equal Opportunity Employer. Sansbury Care Center, Inc. does not discriminate on the basis of Race, Color, Religion, Gender, National Origin, Pregnancy, Marital Status, Citizenship, Age, Disability, Veterans Status or any other legally protected class. As stated above, you may request assistance in completing this form. Upon employment this will become part of your permanent file.

Employment Application

First Name
*

Middle Name

Last Name
*

Address
*

Specific Position Applying For
*

Referred By

Date Available for Work
*

Telephone Number
*

Email Address
*

Does this position require the use of a vehicle?
*

If this position requires the use of a vehicle: Have you ever been convicted of a moving traffic violation or had your driving priveleges revoked or suspended?

If yes, list all below:

Are you willing to work any shift?

If you are wanting a specific shift what shift are you most interested in and when are you available to start work?
*

Have you ever been convicted of a felony?
*

If "yes," when and what type of offense?

Did you graduate from high school?
*

If no, what is the last grade you completed? Grade average?

GED Obtained?
*

College Name and Address

Check the below box to certify your college degree was earned through the actual completion of college level course work and granted by an accredited college or university where you completed coursework.

Yes, I certify that the above statement is true.

Major

Minor

Did you graduate from college?

If no, list the number of hours completed

If you are still attending, what is your anticipated date of graduation?

Do you have a special license or certification?
*

Certificate(s)

License(s)

Nurse License #

CPR License #

List any awards, honors and/or leadership roles
*

Have you served in the military?
*

If yes, note time served (month/year)

If yes, what branch?

If yes, what was your rank at discharge?

If yes, list any military experience applicable to the position:

Beginning with your most recent employer, please complete the following section:
*

Employer Name and Address

Type of Business
*

Job Title
*

Dates Employed
*

For job reference, call (include name and phone number):
*

Please do not contact this employer:

Starting salary (per hour or week)
*

Ending salary (per hour or week)
*

Supervisor
*

Reason for Leaving
*

Employer Name and Address (#2)

Type of Business

Job Title

Dates Employed

For job reference, call (include name and phone number):

Please do not contact this employer:

Starting salary (per hour or week)

Ending salary (per hour or week)

Supervisor

Reason for Leaving

Employer Name and Address (#3)

Employer Name & Address

Type of Business

Job Title

Dates Employed

For job reference, call (include name and phone number):

Please do not contact this employer:

Starting salary (per hour or week)

Ending salary (per hour or week)

Supervisor

Reason for Leaving

Briefly describe how Sansbury Care Center will benefit from your working here, why you are applying for this position, and/or your strengths and talents:
*

Our Mission

Rooted in the legacy of the Dominican Sisters of Peace, Sansbury Care Center’s mission is to provide high quality, personalized, compassionate care services to the Sisters and the lay women who reside at the facility. We hold five (5) values to this mission: